HPV Vax Rates Fall Short of CDC Recommendation

Only two states require vaccine that prevents cervical cancer

Although many vaccines become mandatory for school-aged children about eight years after the CDC's Advisory Committee on Immunization Practices (ACIP) recommends them, the human papillomavirus vaccine has fallen far behind, new research shows.

HPV vaccines are only required in two states and Washington, D.C. despite being recommended by the ACIP in 2007, Jason L. Schwartz, PhD, MBE, of Princeton University's Center for Human Values, wrote in a research letter published today in the Journal of the American Medical Association.

By comparison, the ACIP recommended that all children get the varicella vaccine in 1996. Eight years later, 39 states required children to be vaccinated against the chickenpox before entering public school. And today all 50 states and Washington, D.C. require it, according to the study.

Schwartz and his team also examined immunization requirements for hepatitis B and meningococcal diseases, and found a similar pattern.

"I think part of this is the fact that this vaccine had a controversial history," Schwartz told MedPage Today and VICENews. "Critics of the vaccine in general were very effective at raising anxiety, raising concern about safety of the vaccine, about the value, about consequences, about adolescent sexual behavior after receiving the vaccine ... That really may have left a bitter taste in the mouths of state legislatures and state health officials."

Shortly after HPV vaccines were licensed, people focused on how the virus was transmitted, rather than the fact that the vaccine prevented a virus that caused cervical cancer, said William Schaffner, MD, of Vanderbilt University in Nashville, Tennessee, who was not involved in the study.

"With attention devoted to the mode of acquisition of the virus, that raised all the issues of sex in young people," Schaffner said. "Lots of parents were saying this may be appropriate for that child down the street, but not for mine."

HPV is the most common sexually transmitted infection (STI), with about 14 million new cases every year in the United States, according to the CDC.

Several studies have debunked the notion that receiving HPV vaccines leads to sexual promiscuity, Schwartz said, adding that HPV vaccines have been proven safe and effective.

Hepatitis B is also sexually transmitted, Schwartz wrote. Yet the hepatitis B vaccine is mandatory in 47 states and Washington, D.C., where it is given to newborns.

Schaffner said when the hepatitis B vaccine was first introduced, however, it was administered to adolescents and sparked the same fears about influencing sexual behavior in the 1980s. In time, the fears faded because studies disproved a link between the vaccine and sexual behavior and it was added to the newborn immunization schedule, he said.

In 2010, the federal Healthy People program announced a goal to have 80% of children between 13 and 15 vaccinated for HPV by 2020. But CDC data show that only 37.6% of adolescent girls and 13.9% of adolescent boys had completed the three-dose series of HPV vaccines in 2013.

"When you think about how this is a vaccine that is remarkably safe and remarkably effective, that's not a good record. In fact, it's appalling," Schaffner said.

Ob/gyn Kimberly S. Gecsi, MD, of UH Case Medical Center in Cleveland, said it's no surprise that the HPV vaccines haven't been widely administered. But, she said, Schwartz's research letter offered a compelling comparison, and made her think about why we rely on school to enforce vaccine coverage in the first place.

"You can argue that schools want to require communicable vaccines like the measles and the chicken pox...but you're not going to get HPV just by being at the school with somebody with HPV," Gecsi said. "The same thing is true with hepatitis B. With hepatitis B, you're trying to change the behavior by requiring it."

Texas became the first U.S. state to require HPV vaccines in 2007, when then-Gov. Rick Perry issued an executive order mandating that all girls entering the sixth grade be vaccinated against HPV. But Texas legislators quickly passed a bill to override the executive order.

In July 2014, Rhode Island passed a similar bill, and it will go into effect for boys and girls this August.

Still, some communities have achieved high HPV immunization coverage without mandatory school requirements, a CDC representative said. Rhode Island's mandate doesn't go into effect until next month, yet 77% of adolescent girls in the state have already had at least the first shot in the series, he said.

"We need to have realistic expectations of what school requirements can do," Branam said, adding that school requirements mostly help communities that already have high vaccination rates by ensuring that "stragglers" who've fallen behind on their immunizations are able to catch up before starting school. "However, if the community has very low coverage (say 50%), the school requirement may not be as effective since there may be other issues that is keeping coverage down."

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